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Opening the “Black Box” for Canadian Cardiac Surgery Residency Applicants∗

Open AccessPublished:August 08, 2022DOI:https://doi.org/10.1016/j.cjco.2022.07.017

      Abstract

      Background

      This study reports on the main criteria used by Canadian cardiac surgery residency program committees (RPCs) to select applicants and the perceptions of Canadian medical students interested in cardiac surgery.

      Methods

      A 50-question online survey was sent to all 12 Canadian cardiac surgery RPCs. A similar 52-question online survey targeted at Canadian medical students interested in applying to cardiac surgery residency programs was distributed. Data from both surveys were analyzed using descriptive statistics.

      Results

      A total of 62% of all cardiac surgery RPC members (66 of 106) participated, including committee members from all 12 programs (range: 1-12 members per program; 9%-100% response rate per program) and 67% of program directors (8 of 12). Forty-one Canadian medical students (22 pre-clerks [54%], 2 MD/PhD students [5%], and 17 clinical clerks [41%]) participated. Committee members considered the following criteria to be most important when selecting candidates: on-service clinical performance, the interview, quality of reference letters from cardiac surgeons, and completing a rotation at the target program’s institution. In contrast, the following criteria relating to the candidate were considered to be less important: wanting to practice in the city or province of training, having a connection to the program location, and personally knowing committee members. Medical students’ perceptions were concordant regarding what factors are the most important but they overestimated the influence of non-clinical factors and research productivity in increasing their competitiveness.

      Conclusion

      Canadian cardiac surgery residency programs seek applicants who demonstrate clinical excellence, as assessed by surgical rotations and reference letters from colleagues, and strong interview performance.

      Résumé

      Contexte

      Cette étude fait état des principaux critères utilisés par les comités des programmes de résidence (CPR) canadiens en chirurgie cardiaque pour sélectionner les candidats, ainsi que des perceptions des étudiants en médecine canadiens qui s’intéressent à la chirurgie cardiaque.

      Méthodologie

      Un sondage en ligne comptant 50 questions a été envoyé aux 12 CPR canadiens en chirurgie cardiaque. Un sondage en ligne semblable (comptant 52 questions) a été distribué aux étudiants en médecine qui souhaitaient soumettre leur candidature à un programme de résidence en chirurgie cardiaque au Canada. Les données des deux sondages ont été analysées à l’aide de statistiques descriptives.

      Résultats

      Au total, 62 % des membres de CPR en chirurgie cardiaque (66 sur 106) ont répondu au sondage, y compris des membres des comités des 12 programmes (plage : 1 à 12 membres par programme; taux de réponse de 9 à 100 % par programme) et 67 % des directeurs de programme (8 sur 12). Au total, 41 étudiants en médecine canadiens (22 en préexternat [54 %], 2 étudiants au M.D./Ph. D. [5 %] et 17 stagiaires en formation clinique [41 %]) ont répondu au sondage. Les membres du comité ont considéré les critères suivants comme étant les plus importants dans le choix de candidats : le rendement clinique en service, l’entrevue, la qualité des lettres de recommandation de chirurgiens cardiaques et la réalisation d’un stage dans l’établissement associé au programme. En revanche, les critères suivants étaient considérés comme moins importants : le désir de pratiquer dans la ville ou la province de formation, un lien avec le lieu du programme, et la connaissance personnelle de membres du co-mité. Les perceptions des étudiants en médecine concordaient quant aux facteurs les plus importants, mais les étudiants surestimaient l’influence de facteurs non cliniques et de la productivité en recherche dans l’aspect concurrentiel de leur candidature.

      Conclusion

      Les programmes de résidence canadiens en chirurgie cardiaque recherchent des candidats forts d’une excellence clinique, évaluée par les stages en chirurgie et les lettres de recommandation de collègues, et offrant une bonne performance en entrevue.

      Graphical abstract

      Canadian medical students submit their residency program application through the Canadian Residency Matching Service (CaRMS). Residency program committees (RPCs), often consisting of the program director (PD), staff members, and resident representatives, deliberate on the CaRMS applications to allocate interviews and rank students after the interview process. Since 2013, Canadian residency programs have had to publicly share their selection process goals to increase application transparency.
      • Bandiera G.
      • Abrahams C.
      • Cipolla A.
      • et al.
      Best practices in applications & selection: final report.
      Although details about the Canadian residency application process can be viewed on the CaRMS website (www.carms.ca), becoming a “strong” or competitive candidate for any residency program remains a constant source of stress for students.
      • Clark M.
      • Shah S.
      • Kolla L.
      • et al.
      Post-CaRMS match survey for fourth year medical students.
      • Blissett S.
      • Law C.
      • Morra D.
      • Ginsburg S.
      The relative influence of available resources during the residency match: a national survey of Canadian medical students.
      • Kulasegaram K.
      • D'Eon M.
      Postgraduate medical education selection in Canada: opening the black box.
      Cardiac surgery residency, a Canadian surgical program parallel to the American Integrated Cardiothoracic Surgical Training Program, has become an increasingly popular and competitive option in Canada over the past 10 years. The number of applicants has nearly doubled from 13, 7 of whom ranked cardiac surgery as their first choice, for 11 total residency positions in 2013, to 24, with 16 ranking cardiac surgery as their first choice, for 11 total positions in 2022.
      CaRMS. R-1 match interactive data.
      Prospective students can apply to 12 accredited Canadian cardiac surgery programs—3 programs in Quebec and 9 programs outside Quebec—although some programs do not offer a residency position each year, and programs accept only up to 1 or 2 trainees.
      CaRMS. Program descriptions—first iteration.
      The volume of research exploring the relative importance of various aspects of the residency application package is limited.
      • Obafemi O.O.
      • Mullis D.M.
      • Rogers A.B.
      • Lee A.M.
      Characteristics of integrated thoracic surgery residency matriculants: a survey of program directors.
      ,
      • Smood B.
      • Nguyen S.N.
      • Kelly J.J.
      • Han J.J.
      Integrated cardiothoracic surgery: developing a successful residency application.
      To our knowledge, no studies have been performed on prospective Canadian cardiac surgery trainees, before or during the COVID-19 pandemic. We sought to survey all members from each of the 12 cardiac surgery RPCs with respect to the factors considered most and least important when deliberating on and selecting prospective residents. Moreover, we sought to survey Canadian medical students who were considering or exploring the field of cardiac surgery, to dispel myths around the application process. By doing so, our objective was to decipher the “black box” of applying to this specialty. We hypothesized that clinical performance would be considered most important among RPCs whereas students would overemphasize the importance of research experience.

      Methods

      Survey design

      A working group (K.S., A.M., and T.M.Y.) developed a survey for Canadian cardiac surgery RPCs, adapted from Nguyen DD et al. (2020) (Supplemental Appendix S1).
      • Nguyen D.D.
      • Lee J.Y.
      • Domes T.
      • et al.
      Survey of Canadian urology programs: Which aspects of the Canadian Residency Matching Service (CaRMS) application are the most important?.
      Participants were asked demographic questions, to rank 40 items on a 5-point Likert scale with 1 being “unimportant” and 5 being “most important,” and to list the minimum number of publications required to be viewed as a strong applicant for their program (Supplemental Fig. S1 and Supplemental Tables S1-S3). The survey was written in English and distributed to all 12 Canadian cardiac surgery RPCs through a Web-based platform (Google Forms, Google, Mountain View, CA). Only members of each 2020-2021 RPC could participate; if a program did not offer a residency position during this cycle, members of their 2019-2020 RPC were recruited.
      A similar 52-question online survey targeted at students interested in applying to cardiac surgery residency programs was designed (Supplemental Appendix S2). The survey was written in English and asked participants to assess the same items using the same 5-point Likert scale based on the students’ perceptions of which aspects would define a strong applicant for a Canadian cardiac surgery residency program. The survey was distributed widely across Canadian medical school cardiac surgery interest groups, via organized events and social media platforms. The survey was open to only Canadian medical students for a period of 3 weeks in March 2021. Institutional ethics approval was obtained from the University of Toronto Health Sciences Research Ethics Board.

      Statistical analysis

      Data were analyzed using descriptive statistics. All statistical analyses were performed using Microsoft Excel (Microsoft, Redmond, WA). Statistical significance was set at P < 0.05. Data are presented as mean ± standard deviation. A response to every question was mandatory for survey submission.
      RPC member survey responses were analyzed cumulatively and divided categorically based on demographic factors (experience and location). We defined “relatively inexperienced” as ≤ 2 years on the committee, and “very experienced” as ≥ 7 years on the committee. These criteria were selected in an attempt to balance proportional representation of relatively inexperienced and relatively experienced participants. Quebec and non-Quebec RPC results were compared to examine differences between predominantly Francophone and Anglophone programs. Quebec RPCs consisted of responses from McGill University, the University of Laval, and the University of Montreal. Non-Quebec RPC data consisted of all other RPC responses.
      Survey answers of ≥ 7 were treated as 7 for calculations, where applicable. The PD’s answer choice was selected for the question “Does your institution have a working ranking of students (ranked first to last) prior to conducting interviews?” to resolve discrepancies in RPC answers. Pre-clinical and MD/PhD responses were grouped together for data analysis. All authors have reviewed and approved the final manuscript.

      Results

      Respondent demographics

      Of 106 Canadian RPC members surveyed, 66 (62%) participated, with representation from all 12 Canadian cardiac surgery programs (Table 1). Participant numbers ranged from 1-12 members per program, representing a 9%-100% response rate per program. A total of 8 PDs (67%) participated. The average experience level for RPC members was 3.9 ± 2.5 years, with 35% being relatively inexperienced and 30% being very experienced. Among PDs, the average experience level was 3.9 ± 1.8 years, with 25% being relatively inexperienced and 12.5% being very experienced. A total of 41 Canadian medical students participated—22 pre-clerks (54%), 2 MD/PhD students in their research years (5%), and 17 clerks (41%).
      Table 1Demographic composition of survey responses
      ProgramParticipation, n (%)
      Percentage of total.
      Size of RPCRPC completion, %
      Dalhousie University4 (6)580
      McGill University6 (9)967
      McMaster University8 (9)967
      University of Alberta12 (18)12100
      University of British Columbia5 (8)1145
      University of Calgary8 (12)1173
      University of Laval3 (5)650
      University of Manitoba3 (5)838
      University of Montreal3 (5)560
      University of Ottawa1 (2)119
      University of Toronto10 (15)1191
      Western University5 (8)863
      Total6610662
      Experience on RPC, yParticipation, n (%)
      Percentage of total.
      PD experience on RPC, n (%)
      Percentage of total.
      0 (First year on RPC)6 (9)0 (0)
      17 (11)0 (0)
      210 (15)2 (25)
      310 (15)3 (37.5)
      44 (6)0 (0)
      58 (12)1 (12.5)
      61 (2)1 (12.5)
      7+20 (30)1 (12.5)
      Total668
      Mean ± SD, y3.9 ± 2.53.9 ± 1.8
      Medical school training levelParticipation, n (%)
      Percentage of total.
      Preclinical (first/second year)22 (54)
      PhD portion of MD/PhD2 (5)
      Clinical clerk (third/fourth year)17 (41)
      Total41
      PD, program director; RPC, residency program committee; SD, standard deviation; y, years.
      Percentage of total.

      RPC responses

      Perceptions regarding what factors are most and least important were similar between programs and among RPC categories (Figs. 1 and 2; Supplemental Tables S1 and S2). For all groups, performance during rotation(s) at program institution, quality of/performance at interview, stress management during interview, and quality of reference letters from cardiac surgeons were among the 5 most important factors. Desire to practice in the city or province of the program, connection to the program location, having a higher degree, having reference letters from non-cardiac surgeons, and desire to work in a community setting were among the least important factors. Among Quebec RPC members, English proficiency was seen as being more important than French proficiency, with Likert scores of 4.00 ± 0.95 and 3.58 ± 1.44, respectively (Supplemental Table S2).
      Figure thumbnail gr1
      Figure 1The 5 most-important aspects of the application across residency program committee (RPC) and medical student categories (mean ± standard deviation).
      Figure thumbnail gr2
      Figure 2The 5 least-important aspects of the application across residency program committee (RPC) and medical student categories (mean ± standard deviation).
      Despite the similarities, several statistically significant differences exist between very experienced and relatively inexperienced RPC members and between Quebec and non-Quebec RPC members (Supplemental Table S3). Compared to relatively inexperienced RPC members, very experienced RPC members placed a greater importance on completing a rotation with an RPC member (P = 0.047), clerkship academic performance (P = 0.04), and minimum number of overall authored publications (P = 0.02). Compared to non-Quebec RPC members, Quebec RPC members placed a greater importance on preclinical academic awards (P = 0.01), entrepreneurial endeavors (P = 0.02), having a higher degree (P = 0.04), French proficiency (P < 0.001), and having reference letters from non-cardiac surgeons (P = 0.03).

      Medical student responses

      All medical student respondents expressed interest in cardiac surgery. Medical students’ perceptions of most and least important factors in a candidate’s application were similar for clerkship vs pre-clerkship students (Figs. 1 and 2). In both groups, performance during rotation(s) at the program institution, quality of reference letters from cardiac surgeons, and quality of/performance at the interview were among the 5 most important factors, and French proficiency and entrepreneurial endeavors were among the 5 least important factors. The overall patterns were similar for the 2 groups, with slight differences in relative ordering.
      Despite the similarities, statistically significant differences were found in the relative weight of various factors (Supplemental Table S3). Pre-clerkship students perceived cardiac surgery as being a more difficult program to match into, compared to other CaRMS direct-entry specialties (P = 0.01) and other CaRMS surgical specialties (P = 0.03), compared to clerkship students. Pre-clerkship students believed candidates needed more total authored research publications to be strong applicants (P = 0.01). Clerkship students were more likely to consider future application to a Canadian cardiac surgery residency program (P < 0.001).

      RPC vs medical student responses

      Medical students’ perceptions regarding what factors are most important were concordant with the RPC members’ choices (Fig. 2). However, medical students overvalued the importance of research productivity and placed statistically significantly more weight on the importance of many non-clinical aspects of the CaRMS application (Fig. 3). Compared to cumulative RPC member responses, medical students believed that a candidate requires a minimum of 1.60 more authored publications related to cardiac surgery (P < 0.001), 1.05 more first-author publications related to cardiac surgery (P < 0.001), 2.13 more overall authored publications (P < 0.001), and 1.33 more overall first-author publications (P < 0.001) to be a strong applicant. Of note, RPC members placed higher emphasis than did medical students on preclinical academic performance (P = 0.02).
      Figure thumbnail gr3
      Figure 3Statistically significant differences between cumulative medical students and cumulative residency program committee (RPC) members; t-value calculated as Average 1–Average 2, with values > 0 indicating that medical students place more weight on the relative importance. ∗Minimum number of publications to be considered a strong applicant.
      Moreover, although 33 medical students (80%) believed institutions have pre-interview student rankings, 11 programs (92%) indicated that they do not have such rankings (Table 2).
      Table 2Pre-interview student rankings
      QuestionResponseCumulative RPCCumulative medical students
      Does your institution have a working ranking of students prior to conducting interviews?Yes1 (8)33 (80)
      No11 (92)8 (20)
      Values are n (%).
      RPC, residency program committee.

      Discussion

      This survey focused on the perceived importance of various aspects of the CaRMS application and interview process among Canadian cardiac surgery RPCs and Canadian medical students interested in this specialty. We report a high degree of homogeneity in RPC member answers with respect to what factors are the most and least important to be considered a strong applicant. We also report that medical students’ perceptions were concordant regarding what the most important factors are but they also revealed several misconceptions. The study results confirmed our research hypothesis.
      Unlike cardiothoracic residency and fellowship streams in the US, Canadian cardiac surgery programs do not place weight on standardized examinations such as the USMLE Step 1 and Step 2 CK scores. Canadian cardiac surgery programs appear to place the greatest value on the clinical excellence of their prospective applicants. This factor was assessed by performance during institutional rotations, reference letters from colleagues, interview performance, and to a lesser degree, clerkship academic performance and efficient management of patients on the ward. The finding that medical students viewed these factors as the most important is reassuring. Variability in these overall patterns within RPC categories was minimal. This finding highlights the uniformly high standards upheld across all Canadian cardiac surgery programs.

      Misconceptions

      This study identified several misconceptions held by Canadian medical students. First, the importance of research productivity is overvalued by medical students. A statistically significant difference was found in the perceptions of medical students vs RPC members regarding the minimum total number of first-author and overall research publications, both related and unrelated to cardiac surgery, required to help define a strong applicant. Previous studies have highlighted the finding that although medical students allocate substantial time to research productivity in hopes of increasing their competitiveness, no added benefit seems to be accrued from reporting more research activities.
      • Green M.
      • Jones P.
      • Thomas J.X.
      Selection criteria for residency: results of a national program directors survey.
      • Lakoff J.
      • Howse K.
      • Cofie N.
      • Heeneman S.
      • Dalgarno N.
      Analysis of factors affecting Canadian medical students’ success in the residency match.
      • Hill M.R.
      • Goicochea S.
      • Merlo L.F.
      In their own words: stressors facing medical students in the millennial generation.
      Surveys of program directors across various medical and surgical disciplines have demonstrated that research has low to moderate importance in applicant rankings.
      • Obafemi O.O.
      • Mullis D.M.
      • Rogers A.B.
      • Lee A.M.
      Characteristics of integrated thoracic surgery residency matriculants: a survey of program directors.
      ,
      • Green M.
      • Jones P.
      • Thomas J.X.
      Selection criteria for residency: results of a national program directors survey.
      ,
      • Melendez M.M.
      • Xu X.
      • Sexton T.R.
      • Shapiro M.J.
      • Mohan E.P.
      The importance of basic science and clinical research as a selection criterion for general surgery residency programs.
      ,
      • Negaard M.
      • Assimacopoulos E.
      • Harland K.
      • Van Heukelom J.
      Emergency medicine residency selection criteria: an update and comparison.
      Cardiac surgery is, however, a largely academic specialty. In the American Integrated Cardiothoracic Surgery Training Program, the average applicant had a total academic profile of 16.5 abstracts, presentations, and publications in the 2021 Association of American Medical Colleges (AAMC) Table B1 report.
      American Association of Medical Colleges
      Table B1. Test scores and experiences of first-year residents, by specialty.
      Not surprisingly, most Canadian cardiac surgery programs cited having several authored papers as important in being considered a competitive applicant, with some programs placing more emphasis than others on academia (Supplemental Table S1). Although this study provides general information on a national level, applicants should know what the idiosyncrasies are of each program to which they apply. An interesting finding is that research was regarded as more important among very experienced RPC members, compared to relatively inexperienced RPC members, particularly the number of total first-authored publications, either related or unrelated to cardiac surgery. This finding may reflect a cultural evolution, with research productivity being more highly valued among older surgeons. Some more senior surgeons may feel that research productivity during medical school is a harbinger of academic success during residency and as a staff surgeon. Previous studies have demonstrated a positive correlation between medical school research productivity and future academic success.
      • Dorsey E.R.
      • Raphael B.A.
      • Balcer L.J.
      • Galetta S.L.
      Predictors of future publication record and academic rank in a cohort of neurology residents.
      • Rezek I.
      • McDonald R.J.
      • Kallmes D.F.
      Pre-residency publication rate strongly predicts future academic radiology potential.
      • Yang G.
      • Zaid U.B.
      • Erickson B.A.
      • et al.
      Urology resident publication output and its relationship to future academic achievement.
      • Grimm L.J.
      • Shapiro L.M.
      • Singhapricha T.
      • et al.
      Predictors of an academic career on radiology residency applications.
      • Kohlert S.
      • Zuccaro L.
      • McLean L.
      • Macdonald K.
      Does medical school research productivity predict a resident’s research productivity during residency?.
      • Wang H.
      • Bajaj S.S.
      • Williams K.M.
      • et al.
      Early engagement in cardiothoracic surgery research enhances future academic productivity.
      Relatively inexperienced committee members are often residents or junior staff surgeons who may prioritize recruiting a teammate who has a strong work ethic and personal skills rather than high research productivity. Canadian students can be reassured by the balance of experience, and thus perceptions, among members of RPCs, and by the low threshold for authorship on research publications required for applicants to be considered competitive.
      We also report several non-clinical misconceptions held by medical students. Medical students placed significantly more importance on the candidate’s connection to the program, desire to practice in the city and/or province of the program, and having and/or expressing desire to attain a higher degree. Medical students can be encouraged by the relative unimportance of these factors in candidate selection. One may postulate that the prevalence of fellowship training among cardiac surgery trainees and job recruiting during and after such fellowships account for the relative unimportance of these factors.
      • Shah A.A.
      • Aftab M.
      • Tchantchaleishvili V.
      • et al.
      Characterising the operative experience of cardiac surgical trainees: What are residents really doing in the operating room?.
      • Tchantchaleishvili V.
      • LePar D.J.
      • Odell D.D.
      • et al.
      Predictors of career choice among cardiothoracic surgery trainees.
      • Bergquist C.S.
      • Brescia A.A.
      • Watt T.M.F.
      • Pienta M.J.
      • Bolling S.F.
      Super fellowships among cardiothoracic trainees: prevalence and motivations.
      Furthermore, cardiac surgery programs in Quebec provide instruction either primarily in French or by immersing trainees within predominantly Francophone communities, which is a barrier to entry for some applicants. However, high proficiency in French is not critical to Quebec RPC members in deciding on candidate competitiveness. Rather, conversational speaking ability, writing ability, and French reading comprehension serve as mandatory benchmarks to ensure that trainees can communicate with patients and interdisciplinary hospital staff.
      Of note, most Canadian cardiac surgery programs do not conduct pre-interview candidate ranking. This approach provides an equal playing field wherein applicants can best connect with RPC members and differentiate themselves during the interview stage. Applicants must understand that being given an interview indicates a program’s interest in the candidate. Candidates are encouraged to use the interview as an opportunity to showcase their suitability for a specific program and the unique aspects they would bring to it. In particular, candidates may consider highlighting how they could improve the program for other residents and the institution if they are matched into it.
      Although all medical students were interested in applying to a Canadian cardiac surgery position, pre-clerkship students were more likely to view cardiac surgery programs as being more difficult to match into than other CaRMS direct-entry and surgical specialties and were less confident that they would apply when the time came. Pre-clerkship students’ relative unfamiliarity with other specialties, in part owing to their being at an early stage in their career exploration, may account for these results. However, one must wonder whether these statistically significant observations are due to applicants' misconceptions and how much they are a function of applicants being from medical school programs that provide less exposure to cardiac surgery mentors, research, and operative experiences.

      Implications

      Canadian medical schools are heterogeneous in the clinical exposure and preclinical cardiac surgery course content they provide.
      • Noly P.E.
      • Rubens F.D.
      • Ouzounian M.
      • et al.
      Cardiac surgery training in Canada: current state and future perspectives.
      Access to cardiac surgeons for career exposure and mentorship guidance, particularly relating to cardiac surgery residency applications, can therefore be limited for some students. Our study findings may therefore provide increased transparency in the selection process and serve as a comprehensive, informal guide for prospective students who are confused about how to become competitive candidates. This guidance is particularly helpful for students who would otherwise rely on online forums, such as Premed 101 Forums (forums.premed101.com), classmates, family, and their own assumptions when determining what factors are sought out by those reviewing cardiac surgery residency applications.
      • Clark M.
      • Shah S.
      • Kolla L.
      • et al.
      Post-CaRMS match survey for fourth year medical students.
      Our study findings also may help prospective American candidates applying to integrated cardiothoracic residency programs. Highlighting Canadian medical student misconceptions may also motivate pre-clerkship students to give stronger consideration to a career in cardiac surgery. Notably, historically underrepresented medical students may no longer consider misconceptions as being barriers to entry, such as there being a need for either extensive research authorship, connections to a program location, or a desire to practice in the city or province of the program. Moreover, outlining these misconceptions also provides PDs with critical information to better tailor their informal, open-house events, and informs cardiac surgeons in mentorship roles.
      Our study also lends itself to follow-up data collection. One must wonder what impact current COVID-19 pandemic restrictions, such as interviews conducted through Web-based platforms and no Canadian away electives, have on resident recruitment. Current restrictions save students money on travelling fees but prevent them from interacting with the culture, residents, and staff at each program. Future research should examine the evolution of resident ranking throughout and after the COVID-19 pandemic. This current study may also inspire similar research within and between other CaRMS direct-entry specialties for increased transparency and reassurance for students. Future research also should examine reasons for statistically significant differences between pre-clerkship and clerkship students with respect to the perceived likelihood of applying to cardiac surgery and the perceived difficulty of matching into this specialty.

      Limitations

      The study has limitations at the RPC respondent level. Notably, 4 PDs did not participate, representing one-third of the programs. Although this lack of participation likely did not substantially affect the results, the PDs have an impactful voice and make the final decision on their program’s ranking list. Additionally, the small sample size (n = 62 RPC members) across only one RPC cohort year may limit the long-term applicability of the results. However, the heterogeneity in RPC experience and the overall agreement among RPC members regarding what factors are most and least important s suggest that results would be similar if participation had been increased across many RPC cohorts. Future investigations should repeat this study every 5-10 years to determine if perceptions have changed.
      Survey-specific limitations include the subjective interpretation of questions and use of a nonvalidated survey. Additionally, future investigations should examine the impact of demographic diversity (sex, age, socioeconomic status, race, and belonging to a group that is traditionally unrepresented in medicine) on resident selection and include a short-answer portion to capture factors not listed as answer choices. Furthermore, assessment of the individual importance of one factor is difficult when factors are considered in combination.
      Finally, the study has limitations at the medical student respondent level. The survey link was distributed electronically across Canadian medical schools for only 3 weeks. It is difficult to assess whether students at every Canadian medical school saw the link or had sufficient time to go through it. Given that no directory of medical students contemplating a career in cardiac surgery is currently available, assessing study participation as a response rate is not possible. Our efforts to maintain student anonymity in such a small specialty only further augmented this limitation. Without knowing which medical school program respondents attend, the reach of this survey cannot be assessed, although a lack of representation from one medical school could also indicate a lack of interest from that school’s students.

      Conclusion

      Canadian cardiac surgery residency programs pursue applicants who exhibit clinical excellence at the medical school level. Medical students are aware of the importance of these factors, particularly excellence demonstrated during clerkship rotations, reference letters, and interview performance. However, students overemphasize the necessity of non-clinical factors for application competitiveness. Ideally, future studies will provide information about the evolution of factor importance in applicant selection throughout and after the COVID-19 pandemic. Overall, this comprehensive study will likely prove beneficial in alleviating medical student stress related to applying to Canadian cardiac surgery residency programs and encouraging more students to consider this career path.

      Funding Sources

      The authors have no funding sources to declare.

      Disclosures

      The authors have no conflicts of interests to disclose.

      Acknowledgements

      The authors acknowledge Drs. David Horne, Nadia Clarizia, Rachel Eikelboom, and Saurabh Gupta for their assistance with recruiting participants at their respective institutions.

      Supplementary Material

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